NCLEX - NERVOUS SYSTEM Day3

A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first?

• Client prescribed sumatriptan who has throbbing left temple pain preceded by an aura
• Client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position
• Client with myasthenia gravis who has a fever and increasing difficulty swallowing
• Client with trigeminal neuralgia who reports burning cheek pain after eating ice cream
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The graduate nurse cares for several poststroke clients. Which of the following nursing interventions are appropriate? Select all that apply.

• Implement fall precautions for the client with cerebellar stroke
• Increase lighting for the client with cranial nerve VII affected
• Initiate swallow precautions for the client with cranial nerves IX and X affected
• Place spoon within field of vision for the client with homonymous hemianopsia
• Speak louder in front of the client who has receptive aphasia

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply.

• Assess the client for a carotid pulse
• Determine the client's Glasgow Coma Scale score
• Maintain airway with head-tilt/chin-lift maneuver
• Place a hard cervical collar on the client
• Remove the client from the car onto a backboard

The nurse is assessing a client with delirium. Which of the following findings would the nurse expect to observe? Select all that apply.

• inability to maintain attention
• involuntary movements of the face
• spastic paralysis and hyperreflexia
• incoherent and disorganized speech
• consciousness fluctuating from drowsy to combative

The emergency department nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply.

• Breath smells of alcohol
• Client disoriented to place
• Client reports eyes burning
• History of multiple sclerosis
• Point tenderness over spine

The nurse is caring for a client who had a transsphenoidal hypophysectomy and developed diabetes insipidus. Which of the following findings would the nurse expect to observe? Select all that apply.

• excessive thirst
• increased urine output
• increased serum osmolality
• decreased serum sodium level
• increased urine specific gravity

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply.

• Complete activities such as bathing and dressing as quickly as possible
• Decrease the client's anxiety by limiting the number of choices offered
• Redirect the client if agitated by asking for help with a task or going for a walk
• Remember to interact with the client as an adult, regardless of childlike affect
• Use open-ended questions when communicating with the client

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include? Select all that apply.

• Arrange furniture to allow for free movement
• Keep frequently used items within easy reach
• Lock doors leading to stairwells and outside areas
• Place an identifying symbol on the bathroom door
• Provide a dark room free of shadows for sleeping

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.

• Prepare to suction the client.
• Turn the client to a side-lying position.
• Restrain the client's upper extremities.
• Request assistance from other staff members.
• Use a tongue blade to depress the client's tongue.

The nurse is caring for a client who sustained a traumatic brain injury during a fall. Which of the following findings would require follow-up? Select all that apply.

• amnesia of the events surrounding the fall
• flaccidity of the upper extremities
• widening pulse pressure
• increased drowsiness
• projectile vomiting